For those 70 years of age or older, are any of the following being experienced; YesNo

Delirium

Unexplained or increased falls

Acute functional decline

Worsening of chronic conditions

ACKNOWLEDGEMENT OF COVID19 PANDEMIC RISKName _____________________

Please read the acknowledgement below and initial or sign in all areas indicated.

I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand that the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. For this reason, I understand that the federal and provincial authorities have recommended that Ontarians stay home and avoid close contact with other people. __________ (initial)

I understand the federal and provincial authorities have asked individuals to maintain social distancing of at least two (2) meters and that it is not possible to maintain this distance while receiving orthodontic treatment. __________ (initial)

I understand that some orthodontic procedures can create water and/or blood spray, which is one way that the novel coronavirus can spread. I understand that the ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus. __________ (initial)

I understand that due to the visits of other patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in the orthodontic office. __________ (initial)

I confirm that I DO NOT have any TWO OR MORE or the following symptoms of COVID-19: (i) fever, (ii) new or worsening cough, (iii) sore throat, (iv) runny nose or (v) headache. __________ (initial)

If I received COVID-19 test results in the past three (3) months, the last results I received were negative. _______ (initial) If applicable, approximate date of test: _____________

I confirm that I am not waiting for the results of a test for COVID-19. __________ (initial)

I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days. __________ (initial)

I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have orthodontic treatment completed during the COVID-19 pandemic.